Medical History Form

Your details

Please select
First Name
Surname
Home phone
Work phone
Mobile phone
Email Address
Date of birth
Occupation
Employer

Address

Number
Street Name
Suburb
Post Code

Contact person in case of emergency

Name
Phone number
Relation to you

Health insurance

Health insurance
Ref No
Member No

Information

Who referred you to our practice?
When was your last dental visit?
Why did you leave your last dentist?
What has been your concern with previous dental visits
What is your main dental concern today?


Are your teeth sensitive to:
Does food catch between your teeth?
Do your gums bleed when brushing or flossing?
Do you notice an unpleasant taste or odour in your mouth?
Have you had any complications during or following dental treatment?
Have you had prolonged bleeding after tooth removal or dental surgery?
Is there anything you would like to change about your teeth/gums or their appearance?
Do you grind your teeth or clench your jaws?
Have your jaw muscles ever been sore?
Please describe how you feel about dental treatment (1 to 10)
Do you smoke?

How many per day?
How long have you smoked?


Are you being treated for a medical condition?


Who are your doctors/GP / GP Clinic/ Specialist?
Phone number:
We may request access to medical history or medications for some dental treatments


For Females

Are you pregnant?

What is your due date?

Are you breast feeding?
Are you taking Contraceptives?

Name:

Have you ever been hospitalized or had a major operation?

When?
Please give details


Average alcohol intake per week?
What is your current body weight (kg)?


Do you take any of the following medications/supplements or treatments?
Please list all names of medications with dosage and frequency:


Do you have any allergies or sensitivity to any of the following and describe the reactions:

OTHER- Please specify:


Are you taking any other medications or supplements at present, both prescribed or over the counter?
(Please list with correct dosage & frequency)

Do you have, or have you ever had, any of the following medical conditions?

Other


We like to see you smile with confidence and get the most out of your visits. Please tick the dental care options you'd like to know more about or would consider in the future:


Dental Excellence from time to time offers in-house specials, gift vouchers, products, promotions and information
seminars.
Would you be interested in receiving an invitation?

Would you prefer:


To protect your privacy do you give consent for a third party or family member access to your records?

I give consent for:
Full name of third party or family member:
Contact details:
Relationship:
to:


Please read and tick each section







Patient Name:
Date:
Your name above is accepted as your electronic signature and declaration you have provided true and correct information.